Healthcare Provider Details

I. General information

NPI: 1164990909
Provider Name (Legal Business Name): VIERGINA DUDLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2018
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 SAINT GEORGES AVE STE 106
COLONIA NJ
07067-3427
US

IV. Provider business mailing address

770 WOODLANE RD
WESTAMPTON NJ
08060-3804
US

V. Phone/Fax

Practice location:
  • Phone: 732-534-3526
  • Fax: 732-534-3526
Mailing address:
  • Phone: 609-267-5928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number37LC00325000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: